1865 Cliff Lake Ct Oct 07 2014 0826AM HP Fax page 13
Use BIUE or BLACK Ink
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Clty of�a�a� � Permit#: �
� Perm it Fee: � i�•� �
3830 Pllot Knob Road � �
Eagan MN 55122 � Date Received: �
Phone:(651)675-5675 I I
Fax:(651)675-5694 I Staff: I
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2014 RESIDENTIAL BUILDING PERMIT APPLICATION
Date� r'�'.� � Slte Address• 1�S� ! � � l, / '� l 3i ��G 5'G�,� �a,�� �
r unit�:
Name: �..7 i`'� ��'=::. ���'`�� f�: �''� v�,. Phone:
ResidenU
Owner Address/City!Zip:��9'Y!� C�
Applicant is: Owner �°`� Contractor --
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Description of work: � �° '.c,.� a�'�� --'1
Type of Wcrk I, :
Construction Cost: 3 ?S�'Z'�G. `..� Multi-Family Building: (Yes �/No_�
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Company,�'�%��;���u���'Z�2''�✓'���x�: Contact: !,'�,�.�yi.F,`;��;,,.<
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Contractor Address',����c@ v`r2� s��,.;-�; ��.� �:�r�.-����°��s�:.� city: �s��+��t�����,�
State��`���'° Zip: .�`� G • Phone:�.( •`j`'' �&'',�(�' )��Emell: ?t�.�G..'��' ' �f��°%' �
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License#: ,�',���e�r�� r�i"l Lead Certiflcate#: •����� a-'`=�'"� ' f
If the project is exempt frorn lead certlflcation, please explain why: (see Page 3 for additional information)
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUiLDING
In the lasi 12 morrths,has the Clty ot Eagan i�sued a permit for a slmllar plan based on a master plan?
_Yes _No If yes, date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer&Water Contractor: Phone:
NOTE:P/ans and supportirtg documents thai you subm/t are considered fo be pub/ic intormation. Portlons of
the informatlon may be classJf/ed as non pubtic if you provide specific r+easons tfrat wou/d perm/f ihe City to
conc/ude fhat!he are trade secrets.
CALL BEFORE YOU DIG. Call Gopher State One Call at(651 454-0002 for rolection against underground utility damage. Call 48 hours
before you intend to dig to receive locates oi underground utilities. www. o hersta;eonecall ur
I hereby acknowledge that this information is complete and accurate; that the wo�k will be in canformance with the ordinances and codes ofthe City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; thet the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Exterlor a-agthorized by a bullding permlt Issued tn accordance wNh the Minnesota State 8ullding Code must completed wlthln 180
da perml�suance. �,_,,...-----:-.:.°.�=
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Applicant's Printed Name Applicant's Signature i
Page t ot 3
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Use BLUE or BLACK Ink
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I For O�ce Use �
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C�� 0� nU �� ± Permit#: � j
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� 1J � � Permit Fee: �
3830 Pilot Knob Road � �
Eagan MN 55122 � Date Received: �
Phone: (651)675-5675 t �
Fax: {651)675-5694 I Staff: I
i �
2015 RESIDE(VTIAL..�UILDING PERMIT APPLICATION�� ����,z�
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Date: tL I�/�S Site Address: � �� ��� �� �^c �ow� ����Unit#: ''�
�� � � � Name,.w..v .��1����� � �����.,..,_�° �.o�(_,.S_.,�..���.�,. ��..�W�...�_.�.,.,�Phone:�w�...�.,.,.�.v..,�,.�.� ,�W�� i
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� OV1�1��;r -� Address/City/Zip: S4�"'�' �
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� � Description of work: ��n�
� Type Of lfd(�rk �
� � � Construction Cost:�� ���� ���� ���Multi-Family Building: (Yes �/No� �
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� ( Company:l,l�S �Ytfi�� (��1�G��1� �hc, Contact:��f �1'�t u� ��"' !
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` Address: JSGrb �'G�J�7wvr� G�/J � Su/fe ��S/ City: �� �
Contraeto�r ; /�
� State:�Zip: �5��� Phone: ��3-Sf� .bn'y'�� Email: ��� � �a�.r9�ruy����°`�f,�
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� � License# �G �D� 7�f.3 Lead Cert�ficate# �
� If the project is�exempt from lead certification, please explain�why:�� � ���������������������� �������_��
,..,.�.a.�.�.- w..�,..e,..,...o�w�.�. �uWR_.�.,.�.m.__�.._.�-ti�....�.���._��,,..�_._.�,..�.�.,,�,...�...w.,�.,�.�,.s��_._.�,�.,.......�...�.M,..�.�......�...,..�.._..._.,..�
COMPLETE THIS AREA ONLY IF CONSTRUCTiNG A NEW BUILDING g
� In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? �
�
i
� Yes No If yes,date and address of master plan: �
�
� Licensed Plumber: Phone: �
Mechanical Contractor: Phone: �
Sewer&Water Contractor: Phone:
� Fire Suppression Contractor Phone. �
��IV��7"��.•P���s a�ad��vr�%��do���r�t�f��yo�s�br�a�e co���d to�p�����t#�, Pc��ir�n�af j
� f����s�"r�����a�r be ctass���ed a�no�pu�l���ya�pro�t�s��r�a��s E�a���1 p�rr�a�t#��L��y� �
.��.,�.� co��f�ql�t�t�� a�re tr�le s�cre�`�. .�..:.:���;.��.i
CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.org
I hereby acknowledge that this information is complete and accurate;that the work will be in conformance with the ordinances and codes of the City of
Eagan; that 1 understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Exterior work authorized by a building permit issued in accordance with the Minnesota S t Building Code must be completed within 180
days of permit issuance.
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Applicant's Printed Name Appli s Sign ture
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